Massage (Classical/Swedish)

Does it work?

There is evidence available from six systematic reviews, one non-systematic review, three RCTs and one non-randomised controlled trial assessing various outcomes in the supportive and palliative treatment of cancer. Two systematic reviews on cancer pain suggest that massage therapy may reduce cancer pain (especially surgery-related pain) in the short-term. In terms of other positive health-related quality of life outcomes reported in the studies, findings are not consistent, so no clear pattern is apparent of benefits for specific symptoms. Preliminary evidence also suggests massage may be a helpful supportive care intervention for children with cancer.

In all trials of massage there is a risk of bias affecting reported results, particularly if outcomes are subjective and self-reported, because it is not possible to use adequate blinding. All included reviews and clinical trials had methodological shortcomings that limit their findings.

Cancer pain

Systematic reviews

A systematic review and meta-analysis by Boyd et al. (2016) examined the impact of massage therapy on function in cancer pain 18. Sixteen studies (n= 2034) published until February 2014 were included in the review. Samueli Institute’s Systematic Rapid Evidence Assessment of Literature review process was utilised. Methodological quality was assessed using the SIGN 50 Checklist. Twelve of the studies were considered high quality and four low quality using the checklist. Results of 11 of the 14 studies indicated massage therapy to be effective for treating cancer pain, the remaining 3 studies displayed non-significant results. Three studies (n=167 cancer patients) were pooled for the meta-analysis Standardised Mean Difference (SMD) was −0.20: 95% CI, −0.99 to 0.59 compared with no treatment and −0.55 (95% CI, −1.23 to 0.14; I2 = 89.26%) compared with active comparators for a reduction of pain intensity/severity; the results are therefore not conclusive.

A systematic review by Lee et al (2015) investigated the effects of massage therapy for all types of cancer patients experiencing pain19. Nine electronic databases were searched for studies published through August 2013 in English, Chinese, and Korean. The search included a wide range of databases without language restrictions. To reduce bias caused by the use of different pain assessment scales only trials that used the Visual Analogue Scale (VAS), Brief Pain Inventory (BPI), Numeric Rating Scale (NRS) and Present Pain Inventory (PPI) were included. Methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) and Cochrane risk-of-bias scales. Twelve RCTs (total sample size n=559) were included in the meta-analysis. Results indicated that massage therapy significantly reduced cancer pain (especially surgery-related pain) compared with no massage treatment or conventional care (SMD), −1.25; 95% CI, −1.63 to −0.87). No details of the type of conventional care were provided and several different types of massage were included. Among the various types of massage, foot reflexology appeared to be more effective than body or aroma massage. The review has some limitations. Possible selection bias and the small number of long-term studies included in the analysis therefore render this evidence insufficient to suggest that massage is an effective long-term care option for patients with cancer pain.

This second review by Lee et al 19 demonstrated larger overall effect sizes for massage on cancer pain. Reasons for these differences might be that Lee et al searched a larger number of databases, included other types of massage (reflexology/shiatsu) and did not limit their searches to English language compared with the Boyd et al review; the reviews also used different methods for appraising the methodology of the included trials.

Palliative and supportive care – various outcomes

Systematic reviews

A Cochrane systematic review and meta-analysis by Shin et al. (2016) examined the impact of massage with or without aromatherapy for symptom relief in people with cancer 20. Eight electronic databases were searched for studies published through August 2015 with no language restriction. 19 studies (n=1274) were included in the review. Meta-analysis was conducted on 5 studies. Methodological components of the trials were assessed according to the Cochrane Handbook for Systematic Reviews of Interventions. Evidence was assessed using GRADE (Grading of Recommendations Assessment, Development and Evaluation). Results for massage without aromatherapy were only given in this review. Short-term pain (Present Pain Intensity-Visual Analogue Scale) was greater for the massage group compared with the no-massage group (one RCT, n = 72, mean difference (MD) -1.60, 95% confidence interval (CI) -2.67 to -0.53).

The subgroup analysis for anxiety demonstrated that the anxiety relief for children was greater for the massage group compared with the no-massage group (one RCT, n = 30, MD -14.70, 95% CI -19.33 to -10.07). The size of this effect was not considered clinically significant.

The review demonstrated no differences in effects of massage on depression, mood disturbance, psychological distress, nausea, fatigue, physical symptom distress, or quality of life when compared with no massage. The quality of the included trials was low, the majority of the studies were small and the results were not consistent and not reliable.

In the above-mentioned systematic review by Boyd et al (Boyd 2016) massage therapy was also found to be beneficial for treating fatigue (SMD, −1.06 (95% CI, −2.18 to 0.05; I2 = 92.81% and stress, mood and health-related quality of life (SMD, −1.24 (95% CI, −2.44 to −0.03; I2 = 93.56%) compared to active comparators. This review however provides only limited evidence for the benefits of massage as the size of the benefits are moderate.

A systematic review by Pan et al (2014) examined whether massage interventions provide any measurable benefit in breast cancer-related symptoms21. It assessed various outcomes and used a range of assessment scales such as pressure pain thresholds, the Profile of Mood State Questionnaire, Short Form-8 Health Survey, and Giessen Complaints Inventory. Three electronic databases were searched for studies published to June 2013 in English. Risk of bias of the studies was evaluated using the Cochrane standards. Eighteen RCTs (total sample size n=950) were included. The control groups varied from self-initiated support (four trials), standard healthcare (seven trials), health education classes (two trials), visit (one trial), modified massage treatment (one trial), bandaging (one trial) and self-administered support (one trial). Compared with the control group, the meta-analysis showed that patients receiving regular use of massage had significantly greater reductions in anger, pain, and fatigue. There were no significant differences in depression, anxiety, upper limb lymphedema, cortisol or health-related quality of life. Although a significant reduction in pain was reported in the results, the discussion section highlighted the fact analgesics (and anti-emetics) were used by some of the participants in the trials and this was inadequately controlled. The small number of databases searched and poor methodological quality of some of the included trials (lack of control of non-specific effects and inadequate control groups) limits the quality of this review.

Ernst (2009) 22 conducted a systematic review including RCTs testing the effectiveness of classical massage on palliative and supportive care for cancer patients. Fourteen RCTs published up until November 2008 were identified. Overall results suggested that massage may help relieve pain, nausea, anxiety, fatigue, stress, anger and depression. However, due to methodological shortcomings including small sample sizes, adequate control interventions, and lack of evaluation of long-term effects the evidence was considered not to be conclusive.

Wilkinsonet al.(2006) 23 conducted a systematic review which evaluated the evidence base for the effectiveness of massage (including aromatherapy) for people with cancer, particularly considering quality of life, psychological or physical problems and adverse effects. They considered any trials published up to September 2006, and included RCTs, pre-post test studies and interrupted time-series studies. A total of ten studies were identified. Results suggested that massage may reduce anxiety on a short term, and it may reduce physical symptoms in cancer patients, such as nausea and pain. Again, methodological short-comings prevent firm conclusions.

Controlled clinical trials

A large RCT (n=280) published after the above-mentioned reviews RCT assessed the effect of aromatherapy and classic massage administered in various ways (1st group inhaled aromatic oils, 2nd group classic massage only, 3rd group received massage and inhaled aromatic oils) breast cancer patients receiving chemotherapy on their symptoms and quality of life24. The control group received standard care at the chemotherapy department. A significant difference was found between the control and intervention groups in terms of quality of life scale subdomain scores for general well-being, appetite, sexual function (P < 0.001), physical symptoms and activity, and medical interaction and the overall total quality of life score averages (P < 0.05). For the quality of life scale, the overall and subdomain score averages decreased over time in the control group, whereas an increase was observed in the score averages of the intervention groups. No significant difference was determined between the all groups regarding the quality of life scale score averages for the sleep, perception, social relations, and work performance subdomains (P > 0.05). Aromatherapy massage was found to be especially effective.

An RCT examining the effect of massage therapy on the quality of sleep in breast cancer patients (n=57) reported significant differences (P < 0.001) in the mean scores of quality of sleep before and after in the intervention group, while no significant differences (P > 0.05) were observed in the mean scores of quality of sleep before and after the intervention in the control group 25. Significant differences (P<0.001) were observed in the mean scores of quality of sleep after the intervention between the case and control groups. Participants received twenty minutes of massage three times a week for four weeks.

The feasibility of a massage intervention delivered over the continuum of care, as well as assessment of the immediate and cumulative effects of massage, was examined in an RCT in patients with acute myelogenous leukemia 26. Participants (n=20) received fifty minutes of gentle Swedish massage three times a week for seven weeks. Massage therapy was carried out in both acute care and home settings. Significant improvements in levels of stress and health-related quality of life (P<0.001) were observed in the massage therapy group versus the usual care alone control group. The relatively small size of the study sample limits generalizability. Also, the participants were not followed up post-intervention to examine the level of symptoms following the intervention and treatment period.

Cancer in children

Hughes et al.(2008) 27 evaluated massage as a supportive care intervention for children with cancer. Their non-systematic review concluded that light to medium pressure massage may help reduce pain, anxiety, depression, constipation and high blood pressure in children with cancer. Furthermore they found that massage could help support the function of the immune system during periods of immune suppression following cancer treatments such as chemotherapy. However, these conclusions cannot be considered reliable due to lack of quality assessment and inclusion of a wide range of literature indicating that the review was non-systematic.

Controlled clinical trials

A small (n=25) non-randomised controlled trial investigated the effect of massage therapy on pain and anxiety arising from intrathecal therapy or bone marrow aspiration in children

with cancer 28. The control group received standard care. When the pretest and posttest pain and anxiety levels of the groups were compared, no statistically significant difference was found (P > 0.05). Limitations include a small self—selected sample.

Ovayolu, O., U. Sevig, N. Ovayolu and A. Sevinc. The effect of aromatherapy and massage administered in different ways to women with breast cancer on their symptoms and quality of life. Int J Nurs Pract 2014 20: 408-417.

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